- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.58 / $1,981.39 / $1,981.39
| Professional | | $428.58 | $1,981.39 | $1,981.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.01 / $581.01 / $581.01
| Facility | | $581.01 | $581.01 | $581.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.27 / $581.01 / $581.01
| Professional | | $498.27 | $581.01 | $581.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.01 / $581.01 / $581.01
| Facility | | $581.01 | $581.01 | $581.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.47 / $522.00 / $797.30
| Professional | | $368.47 | $522.00 | $797.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.22 / $665.39 / $1,048.95
| Professional | | $521.22 | $665.39 | $1,048.95 |